International Scholarly Research Network
ISRN Obstetrics and Gynecology
Volume 2011, Article ID 854202, 4 pages
doi:10.5402/2011/854202
Research Article
Experience of Emergency Peripartum Hysterectomies at
a Tertiary Care Hospital in Quetta, Pakistan
Mahrukh Fatima, Pashtoon Murtaza Kasi,
Shahnaz Naseer Baloch, and Abaseen Khan Afghan
Department of Obstetrics and Gynecology, Bolan Medical College, 8-13/36 Kasi Road, Quetta, Balochistan 87300, Pakistan
Correspondence should be addressed to Pashtoon Murtaza Kasi, pashtoon.kasi@gmail.com
Received 25 June 2011; Accepted 4 August 2011
Academic Editor: H. Lashen
Copyright © 2011 Mahrukh Fatima et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Emergency peripartum hysterectomy (EPH) is associated with significant morbidity and mortality worldwide. The purpose of
our paper was to determine the incidence, morbidity, and mortality of EPH done at our institution; the largest tertiary care
government hospital in the city of Quetta, Pakistan. During the study period there were 12,642 deliveries, out of which 46 women
had undergone an EPH, translating into an incidence of∼4 per 1,000 births. Disturbingly, 82.6% of these patients had received no
antenatal care prior to their presentation. There were 4 (8.7%) maternal deaths and 31 (67.4%) perinatal deaths. The commonest
indication noted was uterine rupture in 21 (45.7%) cases. Lack of antenatal care is indeed a modifiable factor that needs to be
addressed to help reduce maternal and fetal morbidity/mortality not only from emergency hysterectomies but also from all other
preventable causes.
1. Introduction
Emergency peripartum hysterectomy (EPH) is associated
with significant morbidity and mortality worldwide. They
are seen more often in developing countries due to decreased
availability and lack of uptake of antenatal care services
especially in the rural areas. There also appears to be a rise
of EPH in the developing world as well [1].
The purpose of our study was to review the emergency
peripartum hysterectomies (EPH) done at our institution.
Our specific aims were then to determine the incidence,
the associated morbidity and mortality, risk factors, and
complications noted at our institution. This would help
highlight the lack of availability and utilization of antenatal
services, identify avoidable factors, and stress the need to
organize health care services so as to improve maternal and
fetal outcome.
2. Materials and Methods
Ethical approval for the study was obtained from the Depart-
ment of Obstetrics and Gynecology, Bolan Medical College,
Quetta, Pakistan, and the research conducted was performed
according to the Declaration of Helsinki.
The study was carried out at the largest tertiary care
government hospital in the city of Quetta in Balochistan, the
largest province in Pakistan. Quetta is a metropolitan city
and the capital of the province. People belonging to different
castes live here along with many refugees who were from
the adjacent wartorn country of Afghanistan and migrated
during the early 1980s and 1990s. This represents one of the
major teaching/tertiary care centers for the province.
Initial part of this work was done and data collected
prospectively from 1994 as part of the FCPS dissertation
of author M. Fatimathr. Due to lack of complete medical
records, we were able to obtain data for all cases that needed
EPH in Gynecology Unit I and II at Sandeman Medical
College Hospital, Quetta, Pakistan over a period of 2 years
from September 25th 1994 to September 1st 1996. Records
after transfer of the gynecology department to another
institution were not available for review.
During this period there were 12,642 deliveries, out
of which 11,960 were vaginal deliveries and 682 caesarean
sections. EPH was defined as one performed after 20 weeks
2 ISRN Obstetrics and Gynecology
gestation for uncontrollable uterine bleeding not responsive
to conservative measures occurring at any time before and
after delivery but within the first 6 weeks postpartum. During
the study period, 46 women were noted to have undergone
an emergency peripartum hysterectomy. Data regarding their
basic demographics, mode of delivery, maternal and fetal
outcome, along with associated complications was then
collected and entered into a database developed in Microsoft
Access 2000. This was then imported into the Statistical
Package for Social Sciences version 14.0 (SPSS Inc., Chicago,
IL, USA) for further analysis.
3. Results and Discussion
As noted above, 46 women were identified who underwent
an emergency peripartum hysterectomy from a total of
12,642 deliveries. This translates into an incidence of ∼4 per
1,000 births. Compared to a study done in Australia where
the incidence was 0.85 per 1000 births, this represents a
rate which is approximately 5-fold higher [1]. In their study,
only 33 EPH were noted among 33,998 births over a 10-year
period whereas in another study in Turkey, 34 cases were
identified over a 10-year period [2]. Similarly, in a study from
a community teaching hospital in New York, 48 cases were
noted over an 8-year period; translating to an incidence of
1.4 per 1000 births [3]. Compared to the aforementioned
numbers, our study just over a 2-year period at a tertiary care
facility serving one of the least developed parts of Pakistan
represents alarmingly high numbers.
Table 1 outlines the basic demographic data regarding
this subset of patients. Disturbingly, 82.6% of these patients
had received no antenatal care prior to their presentation.
The majority of these patients lived in rural areas with the
monthly income of most of them being less than $60.
Review of the morbidity and mortality data is outlined in
Table 2. Unfortunately, this is also associated with poor fetal
outcomes as outlined in Table 3.
There were 4 (8.7%) maternal deaths. One patient died
due to hemorrhagic shock from a ruptured uterus, and
3 patients died due to sepsis after being referred from
periphery of the city after obstructed labor. Compared to a
study in Ghana, “there were no maternal deaths but there
were 7 near-missed fatalities”; whereas a study in Maryland
noted 2 deaths in 34 patients from 1991 to 2001 [4, 5]. A
study done at another tertiary care facility in another city of
Pakistan noted maternal mortality in 4 (19%) of their cases
[6].
The hospital stay of these patients ranged from 8 to 32
days, with a mean of 16.5 days. 20 (43.5%) patients stayed
for 10 days or less, 23 (50%) for 11–20 days, and 3 patients
stayed for 30–32 days. This represents significant healthcare-
associated costs for patients in a country where they often
end up bearing the bulk of the costs, with significant social
and economic consequences.
Among 46 cases of peripartum hysterectomies the range
of parity was from 0–15. Only one patient was primigravida,
who required hysterectomy due to placenta percreta, two
were second gravid both requiring hysterectomies due to
rupture of a previous caesarean scar; while the rest of the
Table 1: Basic demographics and relationship of peripartum hys-
terectomy with parity.
Number of cases %
(1) Peripartum hysterectomy 46
0.36
(∼4 per 1,000
births)
(2) Mode of delivery:
Vaginal 1 2.2%
Caesarean 45 97.8%
(3) Monthly income (Rupees)
<5,000 (∼ $60) 38 82.6%
5,000–10,000 ($60–120) 5 10.9%
>10,000 ($120) 3 6.5%
(4) Area of residence
Rural 32 69.6%
Urban 14 30.4%
(5) Antenatal care visit Received
prior to presentation
Yes 8 17.4%
No 38 82.6%
(6) Relationship with maternal age
20–24 2 4.3%
25–30 10 21.7%
31–35 22 47.8%
36 and above 12 26.0%
(7) Relationship with parity
Primigravida 1 2.2%
1–4 13 28.3%
5–15 32 69.6%
(8) Duration of pregnancy
Full term 38 82.6%
Preterm 2 4.3%
Postterm 6 13.1%
patients were multiparous. About 70% of patients were grand
multipara (5 or more previous deliveries); this was also noted
by Imudia et al. where high parity remained a risk factor for
complications in this subset of patients [7]. Likewise, in a
study from Brigham and Women’s Hospital, Boston, MA, the
“incidence of EPH increased from one in 143 deliveries in
women with one prior live birth and a prior cesarean section
to one in 14 deliveries in multiparous women with four or
more deliveries with a history of a prior cesarean section” [8].
42/46 patients had total abdominal hysterectomy per-
formed; 4 had subtotal hysterectomies. Even though the
numbers are small, subtotal hysterectomy is also a reasonable
alternative in emergency obstetric hysterectomy [9].
The majority of the complications noted in these patients
were infectious complications (fever, wound site infection,
and urinary tract infection) followed by complications
related to the emergent surgery itself. This is similar to
the study done in New York where postoperative febrile
morbidity constituted 34% of the cases [3].
ISRN Obstetrics and Gynecology 3
Table 2: Maternal morbidity and mortality in patients with emer-
gent peripartum hysterectomy.
Variable N %
(1) Maternal mortality 4 8.7%
(2) Mean hospital stay 16.4 days
(3) Mean duration of surgery 120 minutes
(4) Prolonged hospital stay (>14 days) 20 43.5%
(5) Mean units of packed red blood
cells transfused
3.1 units
(6) Total number of packed red blood
cell transfusions (during entire
hospital stay)
1–3 units 33 71.8%
4–6 units 11 23.9%
7 units 2 4.3%
(7) Complications
Fever 20 43.5%
Wound infection 15 32.6%
UTI 10 21.8%
Vesicovaginal fistula 6 13.0%
Ileus 6 13.0%
Transfusion reaction 5 10.9%
Sepsis 5 10.9%
Prolonged intubation 2 4.4%
Ureteral/bladder injury 2 4.4%
Pneumonia 1 2.2%
DVT 1 2.2%
Table 3: Fetal and neonatal outcomes.
(1) Fetal outcome
Stillbirth 29 63%
Live born 17 37%
(2) Neonatal outcome of 17 Liveborn
Neonatal deaths 2
Alive 15
(3) Causes of stillbirth
Ruptured uterus 21 72.4%
Abruptio placentae 5 17.2%
Uterine infection/sepsis 3 10.4%
Almost all the cases were done in an emergent setting
(44/46; 95.6%); only 2 cases were done in an elective fashion.
This is also similar to a study done in Detroit, where 14/158
cases were done in an elective fashion whereas the remainder
144 had to be performed emergently due to complications
encountered at cesarean section [7].
There were 31 (67.4%) perinatal deaths noted at our
institution. Twenty-nine were stillborn, 21 of which were due
to a ruptured uterus and 5 were due to abruption placentae,
3 were due to uterine infection, and 2 were neonatal deaths
due to aspiration pneumonia. These, as noted before, are very
disturbing numbers. In a study from Vienna, the newborns
of these women had a lower birth weight, significantly lower
APGAR scores at 1 and 5 minutes, and were more often
transferred to the neonatal intensive care unit (NICU) [10].
However, the disturbingly high neonatal mortality numbers
here are a possible reflection of delayed presentation of
these patients with no prior antenatal care after having had
instrumentation done at homes or by local untrained birth
attendants.
All the patients were noted to have received blood
transfusion during or in the immediate postoperative period
where indicated. This is also similar to the study done by
Awan et al. in Australia where also all patients required blood
transfusions [1].
In our series of patients, the commonest indication for
an EPH was uterine rupture in 21 (45.7%) cases. In 10
(47.62) cases the etiological factors appeared to be related
to presentation of multipara initially to traditional birth
attendants (TBAs) in rural peripheral areas or at home.
In 4 cases obstructed labor due to malpresentation and
cephalopelvic disproportion neglected by TBAs (or “Dai”,
local untrained birth attendant) appeared to be associated.
One patient (4.76%) had traumatic rupture of uterus
during peripartum manipulation at an outside hospital. 4
patients had rupture of a previous caesarean section scar.
Two patients of lower segment caesarean section were tried at
home by TBAs. Patients who had rupture of unscarred uterus
were all grand multipara and had a history of presenting
initially to a local untrained birth attendants at home prior
to coming to the hospital.
In the remaining patients EPH was due to postpartum
hemorrhage (PPH); 10 (21.74%) cases had PPH due to
uterine atony. Less frequent indications were abruption 5
(10.87%) covualaire uterus, placenta previa 2 (4.35%), and
placenta percreta 2 (4.35%). This is similar to another study
from Hyderabad, Pakistan, where also the main indication
for EPH was rupture of the uterus 7 (33.3%) [6].
The etiologies noted in our subset of patients are different
from the developed world where abnormal placentation
resulting in hemorrhage was the most common cause. In
a study done in The Netherlands, the main indication for
EPH was placenta accreta (50%), followed by uterine atony
(27%) [11]. Similarly, even in a small study of 17 patients in
Saudi Arabia and 54 patients in Republic of Korea, uterine
atony appeared to be the most common cause [12, 13].
In a study from Turkey, uterine rupture was noted to be
the cause in 21% of the cases; there too, uterine atony was
responsible for more than 42% of the cases [14]. In our cases,
instrumentation and possible neglect during the births at
outside peripheral hospitals and/or homes under untrained
birth attendants appears to be associated with the patients
presenting with uterine rupture.
4. Conclusions
(i) In our study, we have identified not only the inci-
dence of emergency peripartum hysterectomy (EPH)
but also highlighted the significant morbidity, mor-
tality, and associated healthcare costs.
4 ISRN Obstetrics and Gynecology
(ii) Lack of antenatal care, which appears to be a com-
mon theme, is indeed a modifiable factor that needs
to be addressed to help reduce maternal and fetal
morbidity/mortality not only from emergency hys-
terectomies but also from all other causes which
appear to be associated with lack of antenatal care
services.
(iii) In developing countries like Pakistan, maternal and
neonatal mortality still represent a significant bur-
den, especially in underdeveloped areas like the city
of Quetta, Pakistan.
(iv) More attention to this would need to be given by
the government and the health departments of the
country for interventions to not only provide health-
care services but also increase uptake of these services
in rural areas of Pakistan, where still a significant
proportion of deliveries are performed under the
supervision of untrained birth attendants.
(v) At the same time, in developing countries, EPH is
almost always an emergency with high risk for signif-
icant blood loss. “The obstetrician should be ready
to do it, and an early decision should save blood and
prevent complications. Postoperative complications,
mostly bleeding and infections may be severe. Early
intervention and proper technique facilitate good
outcomes [15].”
(vi) Since most of these cases are associated with prior
Cesarean section, as noted by Daskalakis et al., “every
attempt should be made to reduce the cesarean
section rate by performing this procedure only for
valid clinical indications [16].”
Acknowledgments
The authors are deeply indebted to the Department of
Obstetrics and Gynecology for their constant support and
encouragement. The authors declare that they have no
conflict of interest. Initial part of this paper was done
and data was collected prospectively as part of the FCPS
dissertation of M. Fatima’s FCPS degree but has not been
published in any form in any journal or publication. The
authors are also very grateful to the hard work put in by Maaz
Khan Afghan and Najia Kasi in retyping parts of the thesis
earlier.
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